Novel Insights from Clinical Practice Autologous Blood Patch Pleurodesis and Endobronchial Valves for Management of Persistent Air Leaks in Two Cases of Tuberculosis.

INTRODUCTION: Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate. CASE PRESENTATION: Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves. CONCLUSION: The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients.

Combination of transbronchoscopic oxygen insufflation and a digital chest drainage system in endobronchial occlusion: a hybrid technique for localization of fistula in intractable pneumothorax.

BACKGROUND: The management of intractable secondary pneumothorax poses a considerable challenge as it is often not indicated for surgery owing to the presence of underlying disease and poor general condition. While endobronchial occlusion has been employed as a non-surgical treatment for intractable secondary pneumothorax, its effectiveness is limited by the difficulty of locating the bronchus leading to the fistula using conventional techniques. This report details a case treated with endobronchial occlusion where the combined use of transbronchoscopic oxygen insufflation and a digital chest drainage system enabled location of the bronchus responsible for a prolonged air leak, leading to the successful treatment of intractable secondary pneumothorax. CASE PRESENTATION: An 83-year-old male, previously diagnosed with chronic hypersensitivity pneumonitis and treated with long-term oxygen therapy and oral corticosteroid, was admitted due to a pneumothorax emergency. Owing to a prolonged air leak after thoracic drainage, the patient was deemed at risk of developing an intractable secondary pneumothorax. Due to his poor respiratory condition, endobronchial occlusion with silicone spigots was performed instead of surgery. The location of the bronchus leading to the fistula was unclear on CT imaging. When the bronchoscope was wedged into each subsegmental bronchus and low-flow oxygen was insufflated, a digital chest drainage system detected a significant increase of the air leak only in B5a and B5b, thus identifying the specific location of the bronchus leading to the fistula. With the occlusion of those bronchi using silicone spigots, the air leakage decreased from 200 mL/min to 20 mL/min, and the addition of an autologous blood patch enabled successful removal of the drainage tube. CONCLUSION: The combination of transbronchoscopic oxygen insufflation with a digital chest drainage system can enhance the therapeutic efficacy of endobronchial occlusion by addressing the problems encountered in conventional techniques, where the ability to identify the leaking bronchus is dependent on factors such as the amount of escaping air and the location of the fistula.

Percutaneous Treatments for Persistent Bronchopleural and Alveolar-Pleural Fistulae.

Percutaneous glue embolization was investigated as a treatment for bronchopleural fistulae (BPFs) and alveolar-pleural fistulae (APFs) associated with persistent air leak. Seven consecutive patients with persistent air leak were treated with percutaneous glue embolization of the BPF/APF from both iatrogenic and spontaneous causes. Treatment was performed using direct n-butyl cyanoacrylate (nBCA) glue injection for discrete, visible fistulae (n = 4), fibrin glue spray for suspected tiny multifocal leaks (n = 2), or both (n = 1). The number of treatments required per patient was 1 (n = 3), 2 (n = 3), or 3 (n = 1). Technical success was achieved in all cases. Follow-up showed resolution of all air leaks, with mean chest tube removal at 7.1 days after the embolization. The follow-up duration ranged from 2 to 47 months. No significant procedure-related morbidity, mortality, or recurrence was encountered. Percutaneous treatment for persistent BPFs and APFs showed good efficacy in this small case series and warrants further investigation.

Bronchopleural Fistula in the Mechanically Ventilated Patient: A Concise Review.

OBJECTIVE: To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of positive-pressure ventilation. To provide guidance of lung isolation, mechanical ventilator, pleural catheter, and endobronchial strategies for the management of bronchopleural fistula on mechanical ventilation. DATA SOURCES: Online search of PubMed and manual review of articles (laboratory and patient studies) was performed. STUDY SELECTION: Articles relevant to bronchopleural fistula, mechanical ventilation in patients with bronchopleural fistula, independent lung ventilation, high-flow ventilatory modes, physiology of persistent air leak, extracorporeal membrane oxygenation, fluid dynamics of bronchopleural fistula airflow, and intrapleural catheter management were selected. Randomized trials, observational studies, case reports, and physiologic studies were included. DATA EXTRACTION: Data from selected studies were qualitatively evaluated for this review. We included data illustrating the physiology of driving pressure across a bronchopleural fistula as well as data, largely from case reports, demonstrating management and outcomes with various ventilator modes, intrapleural catheter techniques, endoscopic placement of occlusion and valve devices, and extracorporeal membrane oxygenation. Themes related to managing persistent air leak with mechanical ventilation were reviewed and extracted. DATA SYNTHESIS: In case reports that demonstrate different approaches to managing patients with bronchopleural fistula requiring mechanical ventilation, common themes emerge. Strategies aimed at decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure decreases airflow across the bronchopleural fistula. CONCLUSIONS: Mechanical ventilation and intrapleural catheter management must be individualized and aimed at reducing air leak. Clinicians should emphasize reducing peak inspiratory pressures, reducing positive end-expiratory pressure, and limiting negative intrapleural pressure. In refractory cases, clinicians can consider lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in appropriate patients as well as definitive management with advanced bronchoscopic placement of valves or occlusion devices.

Successful Endovascular Repair of an Aortobronchial Fistula due to Takayasu Arteritis.

Endovascular approaches to treating a diseased ascending aorta are challenging. We report the use of an endovascular occlusion device for successful closure of a ruptured penetrating atherosclerotic ulcer of an ascending aorta. A 47-year-old female patient with Takayasu arteritis complained of a worsening hemoptysis. She had a history of Bentall procedure for a sinus of Valsalva aneurysm and redo surgery for a ruptured penetrating atherosclerotic ulcer close to the distal anastomosis. She developed methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after the second procedure and required negative pressure wound therapy. Computed tomographic angiography revealed recurrence of a ruptured penetrating aortic ulcer and an aortobronchial fistula. Because of the high risk of redo sternotomy after MRSA mediastinitis, we used an endovascular occlusion device to achieve successful percutaneous closure. The patient was discharged without any complications. Postoperative computed tomography scans showed that the endovascular device was positioned without migration and that complete thrombosis of the penetrating atherosclerotic ulcer was achieved. This is the first report on endovascular repair of a ruptured penetrating atherosclerotic ulcer of the ascending aorta in Takayasu arteritis.

Postoperative Bronchopleural Fistula: A Conservative Way of Treatment in Selected Cases.

BACKGROUND: Postoperative bronchopleural fistula represents a challenging issue for thoracic surgeons. The treatment options reported include bronchoscopic or surgical procedures but the method yielding the best results remains unclear. METHODS: In our thoracic surgery department, between January 2011 and June 2020, 11 patients treated conservatively for early bronchopleural fistula after lobectomy or bilobectomy were reviewed. The fistula size ranged between 2 and 3 mm and complete suture dehiscence. RESULTS: In all 11 patients favorable conditions such as clinical stability, complete expansion of the remaining lung, and resolution of the pleural infection allowed a successful conservative treatment with chest tube drainage. CONCLUSION: In selected cases, conservative management of early bronchopleural fistula after lobectomy or bilobectomy may be an alternative therapeutic option to bronchoscopic or surgical procedures, regardless of the fistula size.

Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy.

BACKGROUND: Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF. METHODS: From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome. RESULTS: In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously (n = 6, 40%) or metachronously (n = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy (n = 3), stenting (n = 6), or suturing (n = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition. CONCLUSION: Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating.

Successful Bronchoscopic Treatment for Postoperative Bronchopleural Fistula Using N-butyl-2-cyanoacrylate (NBCA): Report of a Post-completion Pneumonectomy Case with a History of Induction Chemoradiotherapy Followed by Bilobectomy for Advanced Lung Cancer.

Bronchopleural fistula (BPF) is a severe complication following lung resection. We present the case of a patient with a history of advanced lung cancer, who had undergone induction chemoradiotherapy followed by right middle and lower lobectomy, and who developed BPF after completion right pneumonectomy. Although we had covered the bronchial stump with an omental pedicled flap, BPF was found on postoperative day 19. We covered the fistula with n-butyl-2-cyanoacrylate (NBCA) using bronchoscopy. Although we had to repeat the NBCA treatment, we ultimately cured the patient's BPF and no recurrence was observed up to 15.2 months after surgery.

Successful coil embolisation for an arterio-bronchial fistula in a child presenting catastrophic haemoptysis.

We report the case of a 2-year-old girl who developed catastrophic haemoptysis due to an arterio-bronchial fistula after transcatheter balloon dilatation for a narrowing aortopulmonary shunt. We embolised the fistula while haemoptysis was controlled with the left bronchial block ventilation and haemostatic balloon occlusion of the left subclavian artery. An arterio-bronchial fistula is an extremely rare complication for balloon dilatation of an aortopulmonary shunt.

Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success.

BACKGROUND: Nonmalignant esophago-respiratory fistulas (ERF) are frightening clinical situations, involving surgery with high morbi-mortality rate. We described the endoscopic management of benign ERF. The aim of the study was to describe outcomes of endoscopic treatment of nonmalignant ERF and to analyze factors associated with its success. METHODS: This is a retrospective study involving patients managed for benign ERF in our center between 2012 and 2016. The ERFs were classified into three groups of sizes: (I) punctiform, (II) medium, and (III) large. The primary aim was to document the endoscopic success (= fistula's healing after 6 months). The secondary objectives were characteristics of endoscopic treatment, the functional success and death, and identifying factors associated with success and death. RESULTS: 22 patients were included. The etiologies of ERF were surgery in 12 patients, esophageal dilatation in 3, invasive ventilation in 3, radiation therapy in 2, and tracheostomy in 2. Ninety-three procedures were performed (mean of number: 4.2 ± 4.5/patient). Twenty-one patients had stent placement, eight over-the-scope clips (OTSC), and seven a combined therapy. The endoscopic success rate was 45.5% (n = 10; 67% in punctiform, 50% in medium, and 14% in large ERF), and the functional success was 55% (n = 12). Serious adverse events occurred in 9 patients (40.9%). Six patients died (27%). The persistence of the orifice after 6 months of endoscopic treatment was associated with failure (OR 44; IC95: 3.38-573.4; p = 0.004 multivariate analysis). The orifice's size was associated with mortality [71% of death if large fistulas (p = 0.001) univariate analysis]. CONCLUSION: Endoscopic treatment of ERF leads to 45.5% of successful endoscopic closure and 55.5% of functional success, depending on fistula's orifice size. After 6 months without healing, the chances for success dramatically decrease.

Closure of Bronchopleural Fistula with Mesenchymal Stem Cells: Case Report and Brief Literature Review.

Closure of bronchopleural fistula remains a difficult challenge for clinicians. Although several therapeutic approaches have been proposed, the clinical results are commonly unsatisfactory. Previous reports have indicated that autologous mesenchymal stem cells (MSCs) are useful for aiding treatment of bronchopleural fistula. We report here the use of umbilical cord MSCs to effect the successful closure of a bronchopleural fistula (5 mm) in a 33-year-old woman 6 months after a lobectomy. A review of the relevant literature is included. The use of MSCs may be a promising therapeutic method for the closure of bronchopleural fistula. Randomized controlled trials with larger samples are required.

Therapeutic Outcomes of 15 Postoperative Bronchopleural Fistulas Including Seven Endoscopic Interventions.

Therapeutic approaches to bronchopleural fistula (BPF) closure after lung resection are surgical or endoscopic interventions. We evaluated therapeutic outcomes to determine the optimal approach. We reviewed 15 patients who had developed BPF after lung resection for thoracic malignant diseases at our institution in the 10 years since 2008. The patients were 11 men and 4 women (mean age 68 years). We performed one pneumonectomy, 6 lobectomies, 7 segmentectomies, and one partial resection for malignant diseases. The median interval from lung resection to the BPF diagnosis was 46 days. The BPF-associated mortality rate was 26.7% (4/15). The rate of successful BPF closure was 66.6% (10/15). The endoscopic and surgical intervention success rates were 14.2% (1/7) and 69.2% (9/13), respectively (p<0.01). Of 5 patients who had failed BPF treatments, 4 died, and one transferred out without BPF closure. The therapeutic outcomes were related to preoperative comorbidities, performance status at the BPF diagnosis, time intervals from lung resection to BPF diagnosis, and presence of active pneumonia. The difference between endoscopic and surgical outcomes was nonsignificant, although the surgical intervention success rate was somewhat higher. The selection of endoscopic or surgical intervention for BPF does not significantly affect therapeutic outcomes.

A combined technique using a muscular flap and endobronchial stent to repair complex broncho-oesophageal fistulae supported by ECMO.

INTRODUCTION: Certain broncho-oesophageal fistulae require surgical repair. Herein, we describe an innovative surgical technique combining intercostal flap and endobronchial stenting. CASE REPORTS: Two patients, each with a with complex broncho-oesophageal fistula 2 years after radio-chemotherapy, were hospitalised for severe respiratory infection and extension of the fistula despite previous endoscopic treatment. The first patient presented with respiratory distress (ARDS). She had emergency surgery under extra corporeal membrane oxygenation: oesophagectomy and reconstruction of the left bronchus by a vascularised intercostal flap. Stenting was performed on day 10, due to persistence of the fistula. At 3 months the bronchus was healed, but the patient died of cerebral bleeding. For the second patient, repair was proposed before severe ARDS with the same surgical and ventilatory strategy and a stent was preventively inserted after surgery. After 3 months, the stent was removed and the left bronchus was healed. CONCLUSIONS: Complex post-radiotherapy broncho-oesophageal fistulae should be treated surgically before respiratory complications arise, by combining reconstruction with a vascularised flap and transient stenting.

A case of bronchopericardial fistula with tension pneumopericardium closed successfully by transpericardial intervention: A novel procedure.

A pneumopericardium is a collection of air or gas in the pericardial sac which may cause cardiac tamponade, known as tension pneumopericardium. Tension pneumopericardium is a rare and lethal presentation of bronchopericardial fistula. There are very few reports in the literature of patients surviving with this condition, although prompt diagnosis and early intervention are important. Treatment options are limited. We present a rare case of tension pneumopericardium with cardiogenic shock due to bronchopericardial fistula in a patient with bronchogenic carcinoma who was successfully treated with transpericardial intervention.

Individualized airway-covered stent implantation therapy for thoracogastric airway fistula after esophagectomy.

BACKGROUND: Thoracogastric airway fistula (TGAF) is a rare and dangerous complication of esophagectomy performed for esophageal and cardiac carcinomas. Herein, we aimed to explore the feasibility and efficacy of individualized airway stent implantation for the treatment of TGAF after esophagectomy. METHODS: Based on different TGAF types and relevant data on chest computed tomography, customized airway-covered stents were positioned so as to cover the entrance to the fistula by an interventional radiologist using fluoroscopic guidance. RESULTS: Of the 63 patients with TGAF, 12 had thoracogastric-tracheal fistulas, 14 had thoracogastric-carinal fistulas, 21 had thoracogastric-left main bronchial fistulas, 15 had thoracogastric-right main bronchial fistulas, and 1 had a thoracogastric-right intermediate bronchial fistula. The following different stent types were placed: 7 straight self-expandable covered metallic stents, 2 hinged self-expandable covered metallic stents, 41 Y-shaped self-expandable covered metallic stents, and 13 large Y and small Y paired self-expandable covered metallic stents. In all 59 cases (93.65 %), the implantation was successful at the first attempt, with the procedure times ranging from 5 to 10 min. Esophagograms with water-soluble iodinated contrast showed that the fistulae were completely covered with no contrast flowing into the airways and lungs, and with the stents fully expanded. We recorded four cases (6.35 %) of incomplete or recurrent fistula closure. CONCLUSION: Customized airway-covered stents may be an appropriate palliative therapy for patients with thoracogastric airway fistula who are unfit for surgery or have a high postoperative risk.

Endobronchial Naso-bronchial Lavage: An Alternative Interventional Treatment for Post-lobectomy Bronchopleural Fistula.

BACKGROUND AND STUDY AIMS: Post-lobectomy bronchopleural fistula is a rare complication of lung resection surgery, and proper management is crucial for the successful resolution. Most published papers deal with surgical treatment. We report our experience with a new interventional management, endobronchial naso-bronchial lavage (ENBL). The aim of this study was to evaluate the continuing efficacy and safety of this innovative procedure. PATIENTS AND METHODS: From 2002 to 2012, 17 patients who suffered from post-lobectomy bronchopleural fistula were recruited. An ENBL tube was inserted form nostril through the trachea, bronchus and the fistula into the pleural cavity with bronchoscope. Lavage of the pleural cavity was proceeded form the ENBL tube and drained form thoracostomy drainage tube. All patients were followed up for at least 6 months. RESULT: All patients received total recovery from the post-lobectomy bronchopleural fistula. The ENBL procedure could be finished in 10-15 min. No blooding without control, pneumonia or damage of trachea associated with this procedure occurred. With an at least 6 months' follow-up of the patients, no further intervention was performed. CONCLUSIONS: It suggested that the ENBL may be an alternative interventional treatment for bronchopleural fistula treating other than surgical procedure.